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DIABETES AND COVID-19

It came from a student in health care training. I have diabetes increases the severity of COVID-19. I have a strong family history of diabetes. Kindly throw more light on the subject. In responding to this, I found a fine paper by Singh et al titled “Diabetes in COVID-19: Prevalence, pathophysiology, prognosis and practicalConsiderations and published in Diabetes& Metabolic Syndrome: Clinical Research & Reviews (2020).

The disease burden of coronavirus infectious disease 2019 (COVID-19) caused by

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2) has been

Increasing continuously with more than five million confirmed patients and more than 350,000 deaths globally. With a high prevalence of diabetes, it is important to

understand the special aspects of COVID-19 infection in people with diabetes.

This becomes even more important, as most parts of the world introduced

restrictions on mobility of patients in order to contain the pandemic even though they are being eased in some countries.

Diabetes and associated complications can increase the risk of morbidity and

mortality during acute infections due to suppressed immune

functions. The levels of glycated haemoglobin (HbA1c) greater than 9% have been linked to a60% increased risk of hospitalization and pneumonia-related severity duringbacterial infection. Past viral pandemics have witnessed the association of

diabetes to increased morbidity and mortality. Diabetes was considered as

independent risk factor for complications and death during 2002-2003 outbreak of

Severe Acute Respiratory Syndrome (SARS-CoV-1). Similarly, the presence

of diabetes tripled the risk of hospitalization and quadrupled the risk of intensive

care unit (ICU) admission during Influenza A (H1N1) infection outbreak in 2009.During the 2012 outbreak of Middle East Respiratory Syndrome Coronavirus

(MERS-CoV), diabetes was prevalent in nearly 50% of population. Mortality rate in patients with MERSwho had diabetes was 35%.

Emerging data suggests that COVID-19 is common in patients with diabetes,hypertension, and cardiovascular disease (CVD). Evolving data also suggest that patients of COVID-19 with diabetes are more oftenassociated with severe or critical disease varying from 14-32% in different studies. SARS CoV-2, like SARS CoV utilises angiotensin converting enzyme 2 (ACE-2) as receptor for entry into cell.ACE2 is expressed not only in the type I and II alveolar epithelial cells in the lungsand upper respiratory tract, but also several other locations like heart, endothelium,renal tubular epithelium, intestinal epithelium, and pancreas.

S-glycoprotein on thesurface of SARS CoV2 binds to ACE-2 and causes conformational changes in the ACE-2 receptors are expressed in pancreatic islets. Infection with SARSCoV has been seen to cause hyperglycaemia in people without pre-existingdiabetes.

Hyperglycaemia was seen to persist for 3 years after recovery fromSARS indicating a transient damage to beta cells.

Metformin, a common medication used in diabetes, was significantly

associated with a decreased risk of mortality in patients with chronic lower

respiratory diseases. In a study of 4321 patients with a follow up of 2-

year period, metformin users had a significantly lower risk ofdeath compared with non-metformin users. Patients with coexistent chronic obstructive pulmonary disease and diabetes.

Glycaemic control is important in any patient who has COVID-19. Though data is still evolving, data from other infections like SARS and influenza H1N1

has shown that patients with poor glycaemic control have increased risk of

complications and death. Most patients with mild infection and with

normal oral intake can continue the usual antihyperglycaemic medications.

However, it is advisable to discontinue sodium glucose transporters (SGLT-2) inhibitors because of the risk ofdehydration and euglycaemic ketosis. Metformin may also need to be stopped ifthere is vomiting or poor oral intake. Doses of other antihyperglycemic drugs likesulfonylureas and insulin may have to be altered depending upon the blood glucoselevels.

Blood glucose monitoring poses a special challenge in COVID-19 as it necessitates frequentvisits to patient’s bedside, especially if the patient is critically ill and receiving insulin.

There are several studies about the protective effect of statins in pneumonia.

Statins are known to increase ACE-2 levels and may protect against viral entry of

SARS CoV2. Also, statins are known to inhibit Nuclear factor kappa B

(NFκB) activation and might help in blunting the cytokine storm- a causative factor in COVID-19 complications.

Calcium channel blockers (CCB) have been shown to reduce severity of disease

and mortality in patients with pneumonia, presumably by inhibiting calcium influx

into the cell. It is therefore safe to continue these drugs for control of blood pressurein hypertensive patients. Since CCB has no effect on ACE2 expression, someresearchers have proposed its preferable use in patients with COVID-19 and

hypertension.

So to recap high prevalence of diabetes is seen in patients with SARS-CoV-2 (COVID-19)and the presence of diabetes is a determinant of severity and mortality. Diabetes might facilitate infection by COVID-19 due to increased viral entryinto cell and impaired immune response.Blood glucose control is important for all patients who have diabetes andCOVID-19 infection.Telemedicine can be very useful for the management of patients with diabetes inpresent times with limited access to healthcare facilities.

Once again, make sure you regularly/daily consume polyphenol-rich cocoa to among others reduce your blood glucose, reduce your blood pressure and strengthen your immune system.

DR. EDWARD O. AMPORFUL

CHIEF PHARMACIST

COCOA CLINIC

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